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Over the past several years, there has been significant investment and effort to attest to the various stages of meaningful use, with the goal of achieving better clinical outcomes. One area of MU3 that directly contributes to improved clinical outcomes is implementation of Clinical Decision Support Interventions (CDSi). Medicaid hospitals must implement 5 CDSi and enable drug-drug and/or drug-allergy checking.

From looking at this measure it seems like a walk in the park, but how does your organization fair when it comes to CDS?

Thanks to First Databank, users of EMR’s have been accomplishing drug to drug and drug to allergy checking for over a decade, but what about the edge cases you think will be covered but aren’t? Take a patient that is allergic to contrast for example. Since imaging studies requiring contrast are not drugs, what happens when they are ordered? Are they checking for allergies? In most cases, additional configuration is required to get that flag to pop. This is usually where we come in.

Let’s take a look at a simple CDSi definition provided by CMS.gov

“CDS intervention interaction. Interventions provided to a user must occur when a user is interacting with technology. These interventions should be based on the following data: Problem list; Medication list; Medication allergy list; Laboratory tests; and Vital signs. “

Without a decent rule writer on staff, there are limitations within MEDITECH for accomplishing full CDSi. The primary reason we started recording these discrete data elements in the first place is the glimmer of hope that they would someday prove themselves useful. That day is here, friends. (If you don’t believe me, check out IBM’s Watson diagnosing cancer on YouTube. . .you might want to block off your schedule.)

In collaboration with 9 hospitals as part of a MEDITECH Rules focus group – Project Claire[IT] – we researched and designed intuitive tools to address Clinical Quality Measures (eCQM’s) and incorporated them into a content package. If your organization is struggling to meet these measures or you are interested in improving the patient and provider experience, but don’t have the resources to dedicate to months of research and development, Project Claire[IT]’s accelerated deployment schedule (less than 1 month) can help you meet that mark. Below are just some examples of the eCQM’s and CDS delivered by Project Claire[IT].

Synopsis: The chronic disease management template will only display questions relevant to the Problem List (or other documented confirmed problems since we know not everyone uses the problem list). Popup suggestions trigger orders reminding the provider to complete these chronic condition follow-up items before letting the patient out of their sights. Our goal was to save providers time by ordering all orders in 1 click.

“The Framingham Heart Study noted a dramatic increase in stroke risk associated with atrial fibrillation with advancing age, from 1.5% for those 50 to 59 years of age to 23.5% for those 80 to 89 years of age. Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation.” – CMS71v7

The above quote is taken directly from this measure indicating the use of the Framingham Heart Study we used to identify and risk stratify stroke. Claire[IT] content comes complete with three Framingham Scoring tools:

These calculators use all the aforementioned data elements to drive the score, interpretation and recommendations and the best part is they only require one click.

*User adds BP. BP mean auto calculates. Diabetes and Smoking Status update from the Problem List. Total Cholesterol and HDL update from last lab values. Ten year and comparative risk by age auto calculates.

Synopsis: Not only is this tool built specifically as a conversational assessment, it screens for 4 tiers of mental status within one tool (Mental Status, Education, Cognitive Function and Dementia). The utilization of popup messages allows us to overcome the barrier of character limits and makes for a really smooth display on a tablet or hybrid. Our popups are driven by the primary language field in registration and our content currently consists of English and Spanish translations.

CMS108v6 VTE ProphylaxisCMS190v6 VTE Prophylaxis is the ICU

Synopsis: Patients that have an acute or suspected VTE problem with no orders placed for coumadin (acute/ambulatory or both) receive clinical decision support flags. Clicking the acknowledge tracks the user mnemonic and date/time stamp in an audit trail. Hard stops are also in place if NONE is chosen as a contraindication. The discharge order cannot be filed unless coumadin is ordered or a contraindication is defined. These rules evaluate the problem list and compare it to the medication list to present the provider with the right message.

About Kelly Del GaudioKelly is Principal ConsultantatGalen Healthcare Solutions, and has been optimizing MEDITECH systems for over 10 years. She worked for MEDITECH on an elite 4-person team (the MEDITECH SWAT Team), whose sole concentration was clinical optimization, ROI analysis, MU certification, and achievement of HIMSS EMRAM Stage 6/7. Kelly currently leads Galen’s MEDITECH practice, and championed a focus group, which led to the delivery of Project Claire[IT], a MEDITECH content package of complex rules, assessments, CDS’s, and workflows that evaluate, suggest, and support documentation of chronic and acute problems. Learn more about Kelly in the #IAmGalen series.

About Galen Healthcare Solutions

Galen Healthcare Solutions is an award-winning, #1 in KLAS healthcare IT technical & professional services and solutions company providing high-skilled, cross-platform expertise and proud sponsor of theEMR Clinical Optimization Series. For over a decade, Galen has partnered with more than 300 specialty practices, hospitals, health information exchanges, health systems and integrated delivery networks to provide high-quality, expert level IT consulting services including strategy, optimization, data migration, project management, and interoperability. Galen also delivers a suite of fully integrated products that enhance, automate, and simplify the access and use of clinical patient data within those systems to improve cost-efficiency and quality outcomes. For more information, visit www.galenhealthcare.com. Connect with us onTwitter,FacebookandLinkedIn.

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m finally starting to go through all my notes from HIMSS. Part of that is because I’ve been busy after HIMSS. Part of it is because I like to recover from what I call the #HIMSSHaze. Part of it is that I like to see what still resonates a few weeks after HIMSS.

With that in mind, I was struck by a number of quick hitting comments that I noted from my interview with Dr. Peter Edelstein, CMO at Elsevier. Dr. Edelstein is a fascinating guy that I’ll have to have on a future Healthcare Scene interview. In the meantime, here are some of the quick hitting thoughts he shared about CDS (Clinical Decision Support).

One key point he made is that it seemed like many organizations didn’t have a strategy for CDS. He also aptly pointed out that the same seemed to apply to big data. I agree with him wholeheartedly. If we were to go to a healthcare organization and ask them their CDS strategy I don’t think most of them would have an answer. I think if we dug in, we’d probably find that most of them have essentially deferred their CDS strategy to their EHR vendor. Does anyone else feel like this is a problem?

When I asked Dr. Edelstein what would be his suggested strategy on adopting CDS, he suggested that he’d want to make sure that the CDS solution worked across all provider types. Next he compared the pull CDS solutions (Reference resources, etc) to wearing seat belts in a car and the push CDS solutions (Order sets, care plans, etc) to an airbag in a car. While we certainly need both sets of solutions, he suggested that we should make more of an effort to get the push CDS solutions implemented in healthcare.

I thought the analogy was a great way to look at the various types of CDS solutions. Plus, I agree that we need more push solutions in healthcare. The pull solutions are necessary for some of the most challenging problems, but we all know that when a doctor is busily going about their day they often choose not to check with the pull solutions when they should. The push solutions can be integrated into their workflow so that providers can more easily address any potential issues from within the flow of their day.

Dr. Eldestein also pointed out that Wikipedia is still the most commonly used reference resource despite many studies which have illustrated the medical errors that exist on it. Why do they use it? It’s because it’s simple to use and easily accessible. This is a great illustration of why we need the right CDS information to be more easily available to the doctor at the point of care at the moment they need it.

Definitely some great insights into CDS. What’s great about CDS is that at this point pretty much everyone is using some form of CDS. We’re also seeing CDS integrated more deeply into EHR software. I expect this trend will continue and will become much more sophisticated.

The following is a guest blog post by Bonnie Briggs, Director of Product Management for Wolters Kluwer Health.

As the industry turns towards Stage 2 Meaningful Use (MU) attestation with greater urgency and anticipates the forthcoming criteria for Stage 3 and beyond, healthcare providers are increasingly looking for effective ways to streamline compliance and best position for the future. With so many initiatives competing for limited dollars, the value proposition of any health IT investment is critical to meeting current and future regulatory objectives—and qualifying for attractive incentive payments that can deliver a whopping $7 million to the average 200-bed hospital for Stage 2 alone (based on the current Medicare share and transition factor).

As MU moves past the Stage 1 focus of basic data capture within an EHR, healthcare organizations need to lay a foundation to address the more advanced clinical processes and improved outcomes focus of Stages 2 and 3. Use of clinical decision support (CDS) technology at the point of care is a focal point of compliance as it sets the stage for greater adoption of evidenced-based practices to improve outcomes.

While drug reference and drug interaction data applications are obvious choices for meeting Stage 2 MU CDS requirements for drug-drug, drug-allergy and drug-disease interactions screenings, healthcare organizations need to consider that not all solutions are advanced enough to address other key MU requirements, namely patient education/engagement requirements and HL7 Infobutton capability. Specifically, the industry’s most advanced products can help fill in the gaps by providing appropriate tools for educating and engaging patients and linking clinicians to the most relevant content.

Addressing Patient Education and Limited Health Literacy

Industry research reveals that there is a considerable disconnect between the language of clinicians and the ability of patients to comprehend the relevance and importance of what is being communicated. In fact, nearly half of American adults have some level of limited health literacy when it comes to using and understanding written health information alone, according to the Institute of Medicine (IOM).

One area that has become a focal point of regulatory discussion related to patient education and health literacy is the need to accommodate non-English-speaking patients. The National Standards on Culturally and Linguistically Appropriate Services (CLAS) states that “health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service areas.”

While Stage 2 MU requirements call for the use of EHRs to identify patient-specific education resources, Stage 3 recommendations released by the HITPC Meaningful Use Workgroup earlier this year point to the potential of this rule being expanded to support language needs. Specifically, the recommendation calls for the “use of CEHRT capability to provide patient-specific educational material in non-English speaking patients’ preferred language.”

When considering the value proposition behind the use of CDS technology in the form of drug reference applications, the availability of consumer-level content that addresses a broad array of foreign languages should be considered to best position for compliance going forward. Industry recommendations also suggest that materials be written on a 5th to 7th grade level, using simple sentence structures and short, bulleted statements for easy reading. Other key considerations for effectively engaging patients include age-appropriate illustrations and the provision of materials in larger fonts for the visually impaired.

The Infobutton Challenge

Compliance with MU patient education standards also means that certified EHRs must support the Health Level 7 International Context-Aware Knowledge Retrieval standard, more commonly referred to as the HL7 Infobutton. This industry standard must be used to access patient-specific education materials based on relevance. It may also provide links to referential CDS as an option.

A widely accepted and adopted standard, the Infobutton essentially enables EHRs to generate a view of a patient encounter based on standard patient and provider information. From that information, an EHR application can gather appropriate patient education materials based on the specific details of that case at the click of a button.

The challenge for healthcare organizations will be identifying CDS applications that are equipped to gather patient data in this way. When advanced drug reference applications can aggregate this information from problem lists, medication lists and laboratory results and support Infobutton contextual parameters for identifying appropriate knowledge resources, the value proposition as it pertains to MU compliance is heightened.

Conclusion

When positioning for effective use of CDS at the point of care to meet current and future MU objectives, healthcare organizations need to be careful of making knee-jerk decisions and consider the best technological foundations for long-term success.

While a number of CDS applications on the market can address the basics of drug-drug, drug-allergy and drug-disease interactions screenings, not all are equipped for the broader patient education focus currently unfolding. Considerations should be made for addressing the bigger picture of health literacy and evolving industry standards such as HL7 Infobutton capability.

Bonnie Briggs, RPh, MBA, is the Director of Product Management for Wolters Kluwer Health. She can be reached at bonnie.briggs@wolterskluwer.com.

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Here’s a story of what can happen when a hospital starts out from scratch with the latest in EMR knowledge, rather than having to integrate its system bit by bit.

* Over 95 percent utilization of CPOE (driven predominately by well-designed order set content, HIMSS says)
* Advanced clinical decision support alerts that support best practice protocols
* Smart use of an enterprise data warehouse used to monitor best practice alerts and core measures
* Closed-loop medication administration environment

This award is interesting given that small hospitals have been well behind the curve in Meaningful Use and meeting the HIMSS standards. But there’s some obvious reasons why it’s been so successful.

For one thing, THA has been open only since September. I’ll bet many readers would kill for the clean slate that offers the IT people there. No need for expensive integration projects to bring the new EMR on board; no having to switch staffers from one technology to another; no major transition from paper to digital; and the list of benefits goes on.

Another major factor working in its favor is that THA is part of nonprofit hospital system Texas Health Resources.

A tiny hospital backed by a sizeable IDN is in a different position entirely than an independent critical access hospital, so it’s not exactly astonishing that it zoomed ahead. And when the parent chain already has its own (Epic) install well under way — and an engaged community of users — that knowledge goes a long way.

Too bad most hospitals can’t start out fresh the way THA did. Innovation always comes easier if it isn’t competing with the stuff you’ve already got.

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

CPOE is coming into its own as a technology, after lagging far behind in adoption for many years. And new evidence suggests that this may be a good thing. A new study has concluded that when paired with clinical decision support, CPOE improves order set usability, decreases providers’ mental workload and increases clinical guideline adherence, CMIO reports.

The study, which was published in the September issue of Pediatrics, compares how a group of surgeons at Seattle Children’s Hospital fared using order sets developed on an ad-hoc basis versus sets developed systematically using software design methods.

Researchers Jeffrey Avansino, MD and Michael G. Leu, both of Seattle Children’s, had seven surgeons complete two order sets, one developed on an ad-hoc basis and one developed systematically. The surgeons were working with two clinical scenarios, one in which they were treating a child with perforated appendicitis and the other with a nonperforated appendicitis.

When reviewing the order sets, all of the surgeons preferred the systematically developed order sets, saying that they were more usable and easier to think through. As it turned out, systematically developed sets were also more likely to adhere to clinical guidelines.

All that being said, the authors did express some concern that systems like these might limit resident training, as the sets don’t necessarily explain why a particular decision is being suggested. “We are concerned about the potential of these systems to limit resident training, creating an environment for ‘cookbook medicine’ resulting from prechecked orders,” Avansino and Leu wrote, according to the CMIO piece.

Unfortunately, that’s the kind of tradeoff we’re going to be struggling with often as we further leverage clinical decision support and CPOE. You can’t streamline ordering to a high degree without losing some of the educational aspects of independent decision making — there’s no getting around it. Decision-making is messy and idiosyncratic. We’ll just have to see if carefully-developed order sets are beneficial enough to risk the “cookbook” problem.

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Knowing which vendors have the highest revenue doesn’t have an immediate impact on your HIS installation, but somehow it’s fascinating anyhow. Besides, knowing who’s solvent and what projects they’re pursuing never hurts.

So over the next few weeks, we’re going to share the names and details on the five top earners isolated by HealthData Management magazine, with some details on what they sell, how they’re doing revenue wise and whenever we can, what their market position is. Be sure to check out our full list of Top HIS Vendors.

Bear in mind that by HDM’s definition, we’re talking about vendors who cut across the whole suite of HIS services, from EMRs to revenue cycle management and departmental applications. In most cases, the article hasn’t broken out EMR revenue from its overall revenue projections for each company. But that being said, there’s still some really interesting data here. All estimates are from sources indicated, as compiled by HDM.

McKesson is a $112 billion public company (MCK: NASDAQ) with a hand in most key healthcare sectors. There’s medical supply and pharmacy distribution, HIT solutions which include an EMR and a clinical decision support system, pharmacy automation and medical claims management software….you get the picture. We’re talking a scary big octopus here.

While it continues to be a pharmacy giant, one has to wonder whether McKesson will shift more effort and dollars into HIT when you consider this stat: HIT generated an estimated 44 percent of the company’s profit last year, though it accounted for less than 1 percent of its revenue. Wow.

2011 HIS Revenue: $3.2 billion

2010 HIS Revenue: $3.12 billion

Interesting fact: Believe it or not, MCK has been in business for 175 years; It began as a medical goods supplier in Ye Olde Days.